Saria Hart: Jury concludes serious failings by prison staff contributed to death
Saria Hart was 26 years old when she died by suicide at HMP Foston Hall on 4th October 2019. She was a bubbly, cheeky girl, who loved being around people. She had been in prison before and had a documented history of self-harm / suicide attempts in prison.
Saria arrived at HMP Foston Hall on 16th August 2019. She had been arrested two days earlier, when she had held a knife to her throat and was talked down by police. This information was passed on to the prison, but not recorded anywhere or acted upon.
On 3rd October 2019, Saria was involved in an altercation with prison staff on her wing. She was immediately punished by being put on ‘Zero tolerance / basic regime’ and segregated from other prisoners. She was also removed from her job as a wing cleaner.
That afternoon, she passed a handwritten note to prison staff stating that she wanted to die and had plans to take her own life. A procedure – known as ‘Assessment, Care in Custody and Teamwork’ (ACCT) – was put in place to manage her risk of self-harm. She remained segregated overnight.
On 4th October 2019, an ACCT Assessment Interview was carried out, and Saria re-stated that she wanted to die and had plans to take her own life. She said she had razor blades in her cell, and refused to hand them over. Immediately after the assessment, an ACCT Review was carried out. However, none of the staff in the review – including the mental health nurse - had seen the note or the paperwork from the assessment. They were not aware of her suicidal intent or her past history of self-harm.
Immediately after the review, Saria was taken to an adjudication. She was found guilty and received a further punishment (on top of the basic regime, and the loss of her job), including loss of association, loss of earnings and loss of privileges. She was returned to her wing and was “extremely upset”.
At 15:30, Saria passed another note to prison staff. Again, this expressly stated that she wanted to die, had a plan to take her life, and was going to do it that day. She also stated that she was “done not being listened to” by staff, and that they were not helping her.
The prison staff did not take any action in response to this note. There was evidence that the note was passed around and read by multiple officers, but there was no discussion about what to do, and no action was taken. The note was simply stapled to her ACCT book.
At 16:47 – more than an hour after passing the note - Saria was found in her cell unresponsive. She was taken to Royal Derby Hospital but died in the early hours on 13th October 2019.
Saria had left a final note on her desk which included the following: “I believe prison is the easiest place to commit suicide, especially when officers don’t believe you – it only makes you want to do it more”.
The jury concluded that multiple serious failures by prison staff contributed to Saria’s death, including:
- All relevant information / previous history was not available to be considered in the first ACCT review;
- After the adjudication, no further ACCT case reviews was implemented;
- There was no adequate immediate response to Saria’s second note;
- All previous self-harm / suicide attempt history attempt history was not considered at the first ACCT assessment review; and
- ACCT assessment interview did not appropriately identify Saria’s triggers and risks.
The jury also stated that the absence of Saria’s suicide note and ACCT document during the ACCT review and the adjudication meant that key information regarding her mental health and her risks was not considered and was missed by staff.
The inquest has been reported here:
- BBC News, ‘'No immediate response' to inmate's self-harm plan’
- BBC News, ‘Foston: Prisoner died after being found unresponsive in cell’; and
- Stoke Sentinel, Mum's anguish as Stoke-on-Trent daughter, 26, dies 'begging for help'.
The INQUEST media release can be found here.
Matthew Turner represented Saria’s family at the inquest, instructed by Megan Phillips and Erica San of Bhatt Murphy Solicitors.
The Coroner was HM Senior Coroner for Derby and Derbyshire, Mr Peter Nieto. The other Interested Persons were the Ministry of Justice / HMP Foston Hall and Practice Plus Group.
Matthew is a specialist in deaths in custody. He has secured nine neglect verdicts in different inquests since December 2021.